On November 1, 2014 Brittany Maynard became the face of the aid-in-dying movement when she moved from her California home to Oregon to take advantage of the state’s Death with Dignity Laws. At the time, Physician Assisted Suicide in the state of California was illegal, placing terminally ill patients in a double bind. They could live out their lives in hospice care while potentially dealing with morphine resistant pain, or they could travel across state lines to seek Physician Assisted Death. Several attempts were made in the California legislature to liberalize state legal doctrine regarding end-of-life laws until October 5, 2015 when California Governor Jerry Brown gave final approval to SB 128, the End of Life Option Act.

Last month, on June 9th, SB 128 finally went into effect. The bill allows any autonomous individual over the age of 18 with the capacity for rational decision-making to request lethal medication from their attending physician. If the attending physician and two consulting physicians deem them a qualified candidate for the medication, then they may prescribe the individual with lethal medication [1]. This should be a breakthrough in medical ethics for a state that lacked attention to end-of-life laws up until this point. However, the bill fails to address several major issues.

First, participation in the law is voluntary. This means that a physician can choose whether or not to prescribe medication, nor are there provisions in the bill that require physicians to refer patients to a physician who will prescribe the medication [2]. This bill, written in honor of Brittany Maynard, who couldn’t find appropriate end-of-life services in her own state, fails to help people facing the same problems Ms. Maynard did. Though many doctors are in support of the bill, few express willingness to prescribe medication on moral grounds.

Second, the bill disproportionately affects the poor on multiple levels by creating conflicts of interest between the doctors and the state. Medi-Cal, California’s version of Medicare, spent $91 billion last year with projections of rising costs in the coming years. The average cost of the last year of life for a terminal patients is approximately $33,000 [3]. The costs for a lethal prescription range between $130 and $1000. Physicians participating in the Medi-Cal program are likely to be encouraged to push patients for the cheaper end-of-life option. Unless the families of patients are willing to cover the medical costs privately, families will face either mountains of debt or an expedited death.

Third, the law ascribes the worst form of suffering to those with terminal illness while ignoring the unique conditions of suffering in individuals with dementia, depression, and other medical disorders that impair quality-of-life [4]. Quantifying the magnitude of an individual’s suffering is an impossible task and is based solely on arbitrary factors. While non-terminal Physician Assisted Suicide is a questionable practice to many in the medical community, the blatant lack of attention afforded to such a provision in the bill is worrisome.

Lastly, the bill, which is intended to target the weak and elderly has provisions that: 1. Do not allow the self-administration of the drug; 2. Will not allow a family member to be directly involved in the process, and; 3. Prevent inclusion in advanced directives. End-of-life geriatric patients suffer from idiopathic persistent fatigue as a result of metabolic, muscular, neurologic, and psychological factors [5]. This mentally and physically undermines the patient’s ability to obtain lethal medication, placing an undue burden on the elderly who wish for this alternative in end-of-life care.

Looking broadly at this new end-of-life law, most would agree that it is a step in the right direction as far as increasing patient autonomy and providing more choices for patients and their families. While this is true, lawmakers have ignored important factors that uniquely affect certain marginalized groups. This has resulted in a dichotomy in quality of care within our society. Until changes are made to address these issues, California’s end-of-life law, originally written in honor of an individual who suffered because of the lack of legislation, will only continue to create the same problems that it attempted to solve.

References:

[1] The California End of Life Option Act and Death with Dignity. (2016, January 22). Retrieved July 11, 2016.

[2] Karlamangla, S. (2016, June 6). As California’s End-of-Life law goes into effect, some Doctors question where to draw the line. Retrieved July 11, 2016.

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